VP, Clinical Policy and Risk Management
Core
Oversee Clinical Risk Management, Utilization Management (UM), and Care Management (CM) audit teams to ensure operational compliance, member access to care, and efficiency within Medicare and Medicaid programs.
Role type
VP, Clinical Policy and Risk Management
Builds
CM/UM risk mitigation strategies, compliance frameworks, and audit remediation plans for Medicare/Medicaid operations.
Domain
US Healthcare Insurance (Medicare/Medicaid)
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical risk management, regulatory compliance (CMS/Medicaid), internal controls, process improvement, project management, stakeholder influence, executive presence
Preferred skills
MBA, advanced knowledge of IT technical controls within CM/UM environments
Technologies
CMS Federal regulations, Medicaid State regulations, HIPAA
Responsibilities
Identify and report operational/clinical risks, monitor compliance metrics, implement regulatory changes, lead risk mitigation efforts, oversee business continuity, partner with Legal/Compliance on emerging risks
Seniority
Executive (VP), 10+ years total experience with 6+ in leadership
